Charity Care and Ethics

We as hospital pharmacists
have traditionally minimized
drug expense through formulary
management, negotiation of
contracts, elimination of waste and
diversion, and optional inventory-management
practices. Continuing efforts to
promote cost-effective prescribing,
emphasizing a focus on optional drug-therapy
outcomes, and enabling pharmacists
to modify orders based on therapeutic-interchange policies also have
contributed to limiting drug-expense
inflation. When I look retrospectively at
the growth of my drug budget over the
last 8 years, I am proud of my staff's
efforts to assume a sense of fiscal
responsibility for the clinical enterprise
without compromising the quality of
care we provide.

Despite this success, I am anxious
about our preparedness for the future.
The cost of technology,
skyrocketing pharmacist
salaries, novel drugs
with 5-digit prices, and
individualized therapy
based on genetics promise
to keep us under the
financial microscope
during the foreseeable
future. Without question,
hospital executives will
look to our profession
and its members for
guidance and leadership
to ensure that drug therapy
does not "break the
bank."

Among the many factors
that will increase
costs of providing comprehensive
pharmacy services in the
future, the provision of charity care is
the most daunting. Our first challenge is
to understand the definition of charitycare from an accounting perspective,
from state and federal government perspectives,
and from the hospital perspective.
Presuming that charity care is
differentiated from bad debt, pharmacists
need to appreciate those differences
as well. The concept of
charity care is daunting, because
I believe that we are
approaching a time when hospitals
and society must come
to grips with the financial implications
of providing unabated
charity care. In doing so, I suspect
that the use of drugs for
patients for whom limited or
nonexistent payments are
anticipated will come into
question. These patients are
not limited to "indigent" or
"homeless" people but include
those of "limited means," such
as seniors on fixed incomes
and illegal aliens.

Pharmacists with patient-focused
or administrative responsibilities must
be prepared to actively participate in,
or even lead, discussions about limiting
drug use in selected populations.
As distasteful as this practice sounds,
it appears inevitable unless health
care financing reform takes place. We
will need to understand the principles
of ethics that apply to making health
care decisions, policies that guide
practitioners objectively and consistently,
tools to assess comparative
value of health care interventions, and
much much more. Finally, we will
need to determine where all of this
understanding fits into similar strategic
planning for the entire clinical
enterprise.

It seems to me that the best place
to start is by partnering with schools
of pharmacy and professional associations
to develop educational opportunities
for current practitioners, residents
and future leaders, and all our
students. We must become facile with
ethics, comparative value, and the principles
on which both are based.

Mr. McAllister is director of pharmacyat University of North Carolina (UNC)Hospitals and Clinics and associatedean for clinical affairs at UNCSchool of Pharmacy, Chapel Hill.